RESUMEN
Introduction: Immune checkpoint inhibitors (ICIs) are used in several advanced malignancies and may cause various immune-related adverse events (irAEs). Among them, hematological irAEs are less described. Acquired amegakaryocytic thrombocytopenia (AAT) is a rare immune hematologic disorder characterized by severe thrombocytopenia and complete absence of megakaryocytes in bone marrow. Case presentation: Herein, we present the case of a patient in their 40s with metastatic melanoma who developed an AAT after 12 cycles of nivolumab (anti-PD1). His platelet count decreased by ≤5 × 109/l without other cytopenia. Bone marrow biopsy showed normal cellularity with a complete absence of megakaryocyte and T-CD8+ lymphocyte infiltration. Given the failure of systemic steroids, eltrombopag was started, an oral thrombopoietin receptor agonist (TPO-RA), and his platelet count subsequently increased with complete response. Discussion: Four other cases are described on literature with the same features than non-ICI-related AAT. All cases occurred after anti-PD/PD-L1 treatment with a median onset of 5 weeks. The presentation of our case is quite different with delayed cytopenia. Both ciclosporin and TPO-RA seem to be efficient therapies. Conclusion: TPO-RA could be preferred in oncologic patients, but safety data are still missing to define clear guidelines for immune-related AAT management.
RESUMEN
Puumala orthohantavirus (PUUV) is the most prevalent of the four species of zoonotic hantaviruses found in Europe, causing nephropathia epidemica, a mild form of hemorrhagic fever with acute kidney injury that presents with elevated serum creatinine level, proteinuria and hematuria. The febrile phase of the infection begins with flu-like syndrome and visual disturbance. Laboratory results can show thrombocytopenia. The oliguric phase with elevated serum creatinine level then occurs. Cardiac involvement is sometimes observed, especially ECG abnormality: transient T-waves inversion, generally in the lateral or inferior leads. Marked bradycardia has been exceptionally described. We report the case of a 36-year-old woman with acute PUUV infection. Two days after admission, the patient presented a sinus bradycardia at 25/min. The bradycardia was asymptomatic, persisted one week and resolved spontaneously. Cardiac involvement in Puumala virus infection seems not to be associated with a bad prognosis. Bradycardia in the course of an influenza-like illness in endemic areas should suggest several pathogens such as legionella, Q fever or PUUV virus infection.
